Choosing Affordable Health Insurance

The WannaBuddy blog tends to focus on the preventive side of healthy living: fitness and eating right. But what happens when prevention isn't enough and you need medical care? The variety, cost and complexity of health care options available today truly staggers the mind. Here is an overview of some key concepts, just in case it is time for you to update your coverage.

There are several fundamental models for health insurance, each with strengths and weaknesses. There is no single health insurance plan that is the best for everyone. Family size and make-up, health history, anticipated health events (births, elective surgery, etc.) all play an important role in deciding on the right kind of coverage. Many people choose to adjust their coverage every year, during their employer's open enrollment period. Open enrollment is a special time of the year when you can change your employer-sponsored medical plan without penalty. Changing plans at other times requires a "significant life event" to be permitted. Trust me, most qualifying significant life events are not fun, so be sure to take advantage of open enrollment.

Medical plans fall in to three general types. Basically, you trade off cost for flexibility. Inexpensive plans restrict your access to medical services and plans where you control your care are more expensive. What works for you depends on your personal situation, and how well you can advocate for yourself.

The least expensive, and therefore least flexible, plans are called Health Maintenance Organizations, or HMOs. This insurance connects you to a pre-defined set of doctors, specialists and hospitals. You choose one doctor who is your gateway to all medical services, called your primary care physician. This doctor sees you when you are sick and refers you to specialists within the HMO group if needed. Everything you need is provided by this group. If you don't go outside this group, the medical coverage is pretty inexpensive (relatively speaking of course) but if you want to see a doctor outside the group or don't want to wait for a referral from your primary care physician things get expensive fast.

The most expensive and most flexible plans are called Preferred Provider Organizations, or PPOs. With these plans you have total choice over which doctor, specialist or hospital provides your services. The PPO maintains contractual agreements with some doctors, specialists and hospitals. If you use these contracted services your portion of the cost for service is less than if you go "out of network" and select someone who does not contract with your insurer. In any case you pay a deductible and a co-payment whenever you receive services, but you don't need referrals and can pretty much see anyone you want. The monthly premium is much higher than with an HMO plan, but many people prefer to be the master of their own destiny, health wise.

One middle ground that is gaining popularity is the third option, called a Point of Service, or POS plan. This is a blend of HMO and PPO features. You must select a primary care physician, who manages your access to health services, but you retain the ability to go out of network (at a significantly higher cost to you). This makes sense for people who are happy with HMO services but have one favorite specialist who is not in their HMO plan.

Selecting between these three categories of health plans can be confusing. Think about your upcoming year. Do you anticipate any hospitalization or major medical treatments? If so, an HMO plan might save you a lot of money. Using HMOs does but the burden on you to advocate for yourself. The HMO obviously makes more money if you don't get a lot of medical attention. That means that you may need to press them to get access to specialists or expensive treatments and medications. If you are healthy and comfortable looking out for your best interests, an HMO is a great deal.

PPOs are good in situations where you have chronic illnesses or might need to see specialists for particular issues. The in-network physicians are readily available in most areas. You should check the provider's web site to be sure that your doctors are under contract before signing up.

No matter which plan you choose, remember that the ultimate responsibility for getting good medical care rests with you. Get second opinions before undertaking medical procedures. Ask about alternatives and do some research on your own before accepting treatment plans. Your interests don't exactly match the interests of your provider.

Keep all of your records and bills. Many times a hospital will bill you before they bill the insurance carrier. Wait for the Explanation of Benefits statement that you will get from your insurer before making any payments of your own. It is really hard to get money back from a hospital or doctor. But don't ignore medical bills. The hospital routinely passes unpaid bills to collection agencies and this can damage your credit long after your medical procedure has returned you to health.

Have you found a great (or terrible) medical strategy? Click on the Comment button and share your wisdom!